Rhinitis: Symptoms, Stages, Diagnosis, and Treatment

Rhinitis is inflammation of the nasal cavity mucosa. The disease has common symptoms, regardless of the causes, such as nasal congestion and rhinorrhea (nasal discharge), and specific symptoms characteristic of certain types of rhinitis.

Classification of rhinitis

Acute rhinitis:

• 1st stage of dry irritation;
• 2nd stage of serous discharge;
• 3rd stage of serous-purulent discharge.

Chronic rhinitis:

• Infectious;
• Allergic;
• Hypertrophic;
• Vasomotor;
• Atrophic;
• Ozena.

Etiology

Acute rhinitis – inflammation of the mucosa of the nasal cavity lasting no more than 12 weeks, caused by viruses or bacteria that get on the surface of the epithelium, which trigger a pathological reaction. This disease is not specific. Viruses that most commonly cause acute rhinitis: adenovirus, rhinovirus, RS virus, influenza and parainfluenza viruses. Among the bacteria that cause inflammation of the nasal mucosa, there are strepto- and staphylococci, pneumococci. Acute rhinitis can be the initial manifestation of specific diseases such as measles, scarlatina, diphtheria, meningococcal infection. For the development of the pathological process, in addition to the presence of pathogenic microflora, changes in the mucosa, such as dryness and crusts, a decrease in general or local immunity, the presence of chronic infections in the decompensation phase, are necessary.

Chronic is considered inflammation over 12 weeks, when the course of acute rhinitis over this period it turns into chronic infectious, so the causative agents in these diseases are the same. Also this form of rhinitis can accompany such infectious diseases as syphilis, tuberculosis, histoplasmosis, blastomycosis, leprosy and others, in more detail these pathologies will be considered in the relevant sections.

Allergic rhinitis occurs when the mucosa is exposed to any allergens. The most common are pet hair, dust mites, plant pollen, and mold fungi. When the mucosa is exposed to allergens, an IgE-mediated immune response develops with the release of inflammatory mediators that trigger pathologic reactions. There is a hereditary predisposition and a general tendency to atopy. Also allergic rhinitis may be a manifestation of worm infestation, such as giardiasis, is more common in children, pathogenetically explained by the general sensitization of the body.

Hypertrophicrhinitis most often develops as a consequence of nasal breathing disorders of a post-traumatic nature or chronic inflammation in the nasal cavity or paranasal sinuses.

Vasomotorrhinitis occurs with a violation of neuro-reflex processes, hypersensitivity to various stimuli increases.

Vasomotor rhinitis includes:

• Medicamentous (due to prolonged use of nasal decongestants);
• Hormonal (in pregnant women due to increased progesterone, in patients with thyroid diseases);
• Medication (when taking NSAIDs, aspirin, antihypertensive drugs, ACE inhibitors, b-adrenoblockers, psychotropic drugs, etc.);
• Professional (in contact with dust, wool, sawdust);
• Emotional (during stress);
• Nutritional (when consuming spicy, hot dishes, alcohol).

These forms of rhinitis have different etiologies but similar clinical and pathomorphological manifestations. The diagnosis is made based on a carefully collected medical history and identification of the causal factor.

The etiology of atrophicrhinitis is not fully understood. Some authors attribute the causes of the disease to poor environmental conditions (dry air, dust), trauma or surgery in the nasal cavity, nasal toileting disorders, autoimmune diseases, hormonal changes (menopause, aging) and micronutrient (particularly iron) and vitamin deficiencies.

Ozena, or pruritic runny nose, is a special case of atrophic rhinitis. The causative agent is the bacterium Klebsiella ozaenae, but for the development of the disease in addition to pathogenic microflora, predisposing factors such as foci of chronic infection in the nasal cavity or perinasal sinuses, disturbance of aerodynamics, dryness and the presence of microcracks are necessary.

Anatomy

Acute rhinitis proceeds in 3 stages, successively succeeding each other. Phase 1 of dry irritation is characterized by hyperemia and dryness of the mucosa, this stage lasts from a few hours (more often) to several days.

The stage of serous discharge is characterized by hyperemia and edema of the mucosa, its fullness and small foci of submucosal hemorrhages (petechiae), increased mucus production.

By days 4-5 from the onset of the disease, the discharge becomes mucopurulent due to the overproduction of lymphocytes and desquamated epithelium. With a favorable course, by the end of 7-10 days, the inflammation resolves.

Chronic infectious rhinitis is characterized by nonspecific changes such as mucosal hyperemia, fullness of the nasal conchae, and hyperplasia of the bocaloid cells with increased secretion production.

Allergic rhinitis is characterized by pallor of the mucosa with a cyanotic tint and pronounced edema of the nasal shells, abundant clear mucous discharge. Often allergic rhinitis is combined with chronic polyposis rhinosinusitis, in which case rhinoscopy reveals polyposis-altered mucosa or polyps.

In hypertrophic rhinitis , excess bone tissue of the lower nasal shell throughout its entire length is most often found. Less common are vascular and fibrotic forms, in which there is proliferation of blood vessels or connective tissue in the thickness of the nasal shells.

Vasomotorrhinitis is morphologically characterized by full blood vessels of the cavernous tissue of the nasal shells, they become purple-blue, thickened, the lumen of the nasal passages is rarely narrowed, the number of bocaloid cells increases. When the parasympathetic system is disturbed, there is mucus hyperproduction, and when the sympathetic system is disturbed, there is swelling and nasal congestion.

In atrophicrhinitis in the nasal cavity is found a large number of crusts, mucosa pale pink thinning, matt, “parchment”, with scanty serous-mucous discharge. With the progression of the disease, atrophic processes affect the olfactory nerve and blood vessels of the mucosa.

Ozena is characterized by the same changes as atrophic rhinitis, but with the progression of the process, deep-lying tissues, including the bony part of the nasal shells due to osteoclasts, blood vessels are obliterated, scarred. The number of bocaloid cells is sharply reduced, cilia are absent, due to which mucociliary clearance does not function, the nasal passages are dilated due to the deficiency of nasal shell tissue. Tissue breakdown contributes to the production of a stinky odor. Rhinoscopy reveals a pathologically wide nasal cavity, the posterior wall of the nasopharynx is clearly visible. Crusts of gray-green color abundantly lining the nasal cavity, forming so-called casts.

Symptoms of rhinitis manifestation

Acute rhinitis begins with pronounced difficulty breathing, sneezing, burning in the nose, which corresponds to the 1st phase, there are general symptoms: headache, increased body temperature to subfebrile or febrile values. During the transition to the next phase, abundant mucous discharge is attached, which in contact with the skin in the area of the nasolabial triangle causes its maceration, due to its chemical composition. Nasal congestion worsens, lacrimation appears, some patients note congestion in the ears.

When moving to stage 3 nasal discharge acquires yellow-green color, becomes thicker, stuffiness decreases. In any of the stages there may be pain in the projection of the sinuses due to the development of marked edema of the mucosa in the sinuses themselves and in the places of their exit into the nasal cavity.

Chronic infectiousrhinitis is a sluggish disease in which patients note difficulty in nasal breathing and persistent mucous or mucopurulent discharge with an unpleasant odor, sometimes accompanied by headaches or anosmia.

Allergicrhinitis is characterized by copious serous discharge on contact with the allergen, sneezing, nasal itching and stuffiness, and signs of allergic conjunctivitis with lacrimation and itching in the eyes may also appear. The above complaints are manifested directly by contact with the allergen. Clinically, allergic rhinitis is categorized into seasonal and year-round, persistent and intermittent, mild and moderate. Seasonal rhinitis occurs once or several times a year and is usually associated with the blooming of certain plants, and year-round rhinitis occurs constantly and is more often associated with household allergens (dust mites, pet hair, etc.). Intermittent rhinitis occurs up to 4 days a week or up to 4 weeks a year, while persistent rhinitis is characterized by continuity.

Mild rhinitis is not characterized by sleep disturbances or general activity impairment, while moderate-severe rhinitis, on the contrary, causes significant discomfort that disrupts the usual rhythm of life, negatively affecting sleep and work capacity. It is important to emphasize the close relationship between allergic rhinitis and bronchial asthma, due to a common pathogenetic mechanism. Allergic rhinitis is considered a risk factor in the development of bronchial asthma. It has been proven that without adequate treatment of allergic manifestations in the nose, the course of bronchial asthma significantly worsens. There is also a connection between this pathology and atopy. It usually manifests in childhood.

Hypertrophic rhinitis is characterized by persistent pronounced difficulty in nasal breathing, snoring, less often – anosmia.

Vasomotorrhinitis is characterized by intermittent character of clinical manifestations, periodically appear itching in the nose, sneezing, nasal congestion and watery or mucous discharge, more often flowing down the posterior wall. Patients note the appearance of complaints at changes in temperature or humidity, body position in space (pronounced worsening lying on the side), increased blood pressure, strong odors, etc. Usually manifests in adulthood.

Patients with atrophic rhinitis complain of dryness and itching in the nasal cavity, difficulty breathing, despite the pathologically wide nasal passages, the so-called “empty nose” syndrome, poorly separated crusts, after removal of which does not provide relief, and in some cases may occur nosebleeds. As the process progresses, the olfactory nerves are affected and anosmia develops, the nasal septum may be perforated and nosebleeds may develop. Since ozena is a subspecies of atrophic rhinitis, all of the above complaints will be characteristic of it as well. A distinctive feature is the presence of a persistent stinky odor from the nose, which the patients themselves do not feel, because of which others try to avoid communicating with them, in connection with which the patients suffer mental state. When attempts are made to remove the crusts, they are rejected by the casts, bleeding is weak. General symptomatology includes headache, marked weakness and fatigue.

Diagnosis of rhinitis

A general examination (otorhinolaryngoscopy) is sufficient to diagnose acute or chronic rhinitis in most cases. Assess the nature of complaints, the state of the mucosa and discharge, collect a thorough anamnesis. With a prolonged course, no effect of treatment and the presence of pain in the projection of the paranasal sinuses recommended radiography of the sinuses.

In chronic infectious rhinitis, bacteriologic seeding of nasal discharge is performed to identify the causative agent and determine sensitivity to antibacterial drugs.

Different tests are used to diagnose allergic rhinitis, depending on the clinic’s equipment. Rhinocytogram with quantitative determination of eosinophils in nasal mucus has lost its value today due to uncertain sensitivity, because the absence of eosinophils does not mean that there is no disease, and the presence of eosinophils may also be present in patients with non-allergic rhinitis. The most common method is various skin tests (scarification, prick tests, etc.) in which the allergen is applied on/under the skin and after a certain time a reaction is recorded at the site of contact. “Gold standard” diagnosis of allergic rhinitis – determination of specific IgE to the most common allergens in serum.

To detect hypertrophic bony rhinitis, anemization of the nasal shells is performed. The diagnosis is valid in case of a negative test.

Vasomotor and atrophic rhinitis are established after rhinoscopy, collection of complaints and anamnesis.

In atrophic rhinitis and ozena, bacteriologic examination of the nasal cavity discharge is also performed. A blood test is performed to determine hemoglobin and serum iron levels. If perforation is present, a free edge biopsy with pathomorphologic examination is performed. If symptoms worsen rapidly, the patient should be evaluated for ANCA vasculitis. The diagnosis of ozaena is 100% when Klebsiella ozaenae is detected by microbiologic examination or blood examination with immunologic tests and antibody detection.

Treatment

Treatment of acuterhinitis is symptomatic. Nasal decongestants are prescribed (phenylephrine, xylometazoline, oxymetazoline), which reduce edema and mucous discharge, after which it is recommended to perform nasal toilet with saline solutions or seawater to evacuate pathologic contents from the nasal cavity. In the presence of pronounced general symptoms, it is possible to use NSAIDs (paracetamol, ibuprofen).

The treatment of chronic infectiousrhinitis requires the administration of antibacterial therapy locally or systemically, taking into account sensitivity. Also prescribed is a regular nasal toilet with saline solutions or seawater.

In the treatment of allergicrhinitis, the most important thing is the elimination of the causative factor (allergen). Depending on the severity of the course, combinations of different drugs are prescribed. Intranasal decongestants are used as therapy with a short course of no more than 7-10 days. Antihistamines for local or systemic use are necessarily prescribed. In case of severe symptoms, the use of glucocorticosteroids intranasally for a long time (at least 1 month) or antileukotriene drugs systemically is recommended. The majority of patients can achieve persistent remission with ASIT (allergen-specific immunotherapy), which is an etiotropic method (i.e., it fights the cause of the disease, not the symptoms). The essence of treatment is the long-term introduction of allergens into the patient’s body in minimal quantities (sublingually or subcutaneously). This results in the development of “immunity” to subsequent contacts with the allergen, minimizing unwanted reactions.

Treatment of hypertrophic bonyrhinitis is surgical. It consists of a partial conchotomy, in which excess bone tissue is gently removed, preserving the anatomical landmarks and soft tissues of the nasal shells.

As therapy for vasomotorrhinitis use antihistamines of local or systemic action, topical hormonal drugs for a course of 1 month, it is recommended to regularly moisturize the mucosa with isotonic solutions. If there is no effect from conservative therapy, surgical intervention with the use of various devices (laser coagulation/submucosal vasotomy/radiofrequency or ultrasound destruction, etc.) is performed, in which the nasal shells from the inside are partially damaged and then scarred, reducing in size, while the mucosa remains intact and continues to perform its functions.

In atrophic rhinitis, treatment is aimed at moisturizing the mucosa. For this purpose, sprays based on isotonic solutions, sea water with the addition of dexpanthenol or hyaluronic acid are used. In the absence of contraindications prescribe lubrication of the mucosa with iodine solutions to irritate and stimulate the bocaloid cells and increase the production of mucous secretion. A good effect is observed when treating the mucosa with oil solutions containing vitamins A, D, E, such as sea buckthorn, peach, sesame oil, but they should be used only to a limited extent, as they impair the work of the ciliated epithelium. If pathogenic microorganisms are detected, topical antibacterial therapy is prescribed.

Systemic (preferably parenteral) antibiotic therapy based on sensitivity results is required for the treatment of osseous. Locally, as well as in atrophic rhinitis, regular nasal shower with the use of phys. solution or sea water with the addition of iodine preparations, moisturizing with oil solutions. To achieve a therapeutic effect after softening the crusts, they should be regularly removed and then irrigate the nasal cavity with local antibacterial drugs.